Assessment of Older People's Health and Social Care Needs and ...

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general healthvision and hearingFor each sub-scale, the WDRS has five response op(ions, compared to the Barthel which has justthree response options. This means that the data gathered is more specific and useful to the PHN.Implementation of the ProjectThe project commenced in November 1999 and was completed in February 2000. During this time, allclients aged 75 years and over, with medical cards, were visited and assessed using the WDRS. Theynumbered 3,871 clients in all. Those with scores of 33 or more were identified as being at risk and nursingcare plans were put in place. The project was subsequently audited using a set of questions put toparticipating PHNs and recommendations arising from the audit were implemented. Community RGNs andhome care assistants were employed in January 2001 and have continued to work on the project to date.Intermediate OutcomesThe intermediate outcomes of the project were as follows:a total of 3,871 medical card holders were visited and assessed• of those, 6.4 per cent (274) were found to have a WDRS score of 33 or more. Femalesoutnumbered males by two to onethe most common risk factors were a medical condition combined with living alonewe found that WDRS wcs useful as a measure of disabilityit identified actual as opposed to potential problemsin an audit of care plans, we found thirty-one nursing problemsone of the issues arising was the non-availability of services; specifically home helps and homecare assistants in the numbers required. As a result of identifying this as an issue, we were givenfunding to proVide these services, thus developing the skill mix team in our area• the project represents value for money: 583 maximum dependency patients were provided with apackage of care and maintained at home in 2001; of 989 discharges from Waterford RegionalHospital for the same period, 512 patients were provided with a package of care followingassessment by the area PHN; the total cost of the service for 2001 was £31,525._1---------------------------------Through the WDRS pilot project, we have operationalised an 'at risk' register for older people in ourCommunity Care area. This register is updated monthly by PHNs and helps us to identify older peoplewho will need packages of care.Information from the 'at risk' register is currently being shared with the Accident and EmergencyDepartment of Waterford Regional Hospital on a pilot basis. A directory of PHN's, with their contact details,has been supplied to each ward at Waterford Regional Hospital to facilitate early discharge planning.There are now data available to assist anticipatory service planning, and packages of care providinghome support, have been developed for patients, as outlined earlier.Conference Proceedings
Pathways to Care: Old AgeScreening and Assessment inthe Community: The Approachof Public Health Nurses in theWestern Health BoardMarion Duffy, Public Health Nurse, Western Health Board-----------------------------------This paper provides an overview of the assessment of older people carried out by PHN's in theWestern Health Board area. Specifically, it describes a functional and social assessment screening tooldeveloped for the assessment of older people in our area.The comprehensive assessment of older people is a structured approach to measuring their physical,mental and social functioning in order to identify needs and plan care. The process of assessmentwith an older person is an opportunity to learn more about the individual, his/her current situation,experiences and desires for the future. It is also an opportunity to build a relationship with theindividual, to offer a professionai view on problems and to plan with the indiVidual, family and carers,if appropriate, what treatment, supports and services could best meet needs. The older personshould be at the centre of assessment and should feel empowered by the process.The Assessment of Older People's Needs in the WHBThe WHB Approach to AssessmentThe approach to assessment developed in the Western Health Board area includes a contact andoverview assessment and four specialist assessments that provide a holistic view of an older person'sneeds. These assessments are in the areas of:• twelve activities of daily living• application of a functional and social assessment screening tool• pressure dsk assessment, using the Norton Score• continence assessment.Assessment of Older People's Health and Social Care Needs and Preferences
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